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BRAIN FUNCTION QUESTIONNAIRE

NAME______________________________________


DATE_______________________________________


Part I

Your Life seems incomplete
You feel shy with all but your closest friends
You have feelings of insecurity
You often feel unequal to others
When things go right, you feel undeserving
You feel something is missing in your life
You occasionally fell a low self-worth or self-esteem
You feel inadequate as a person
You frequently feel fearful when there is nothing to fear


Part II

You often feel anxious for no reason
You sometimes feel “free-floating” anxiety
You frequently feel “edgy” and it’s difficult to relax
You often feel a “knot” in your stomach
Falling asleep is sometimes difficult
It’s hard to turn your mind off when you want to relax
You occasionally experience feelings of panic for no reason
You often use alcohol or other sedatives to calm down


Part III

You lack pleasure in life
You feel there are no real rewards in life
You have unexplained lack of concerns for others, even loved ones
You experience decreased parental feelings
Life seems less “colorful” or “flavorful”
Things that used to be “fun” just aren’t any longer
You have become less spiritual or socially concerned person


Part IV

You suffer from a lack of energy
You often find it difficult to “get going”
You suffer from decreased drive
You often start projects and then don’t finish them
You frequently feel a need to sleep or “hibernate”
You feel depressed a good deal of the time
You occasionally feel paranoid
Your survival seems threatened
You are bored a great deal of the time


Part V

It’s hard for you to go to sleep
You can’t stay asleep
You often find yourself irritable
Your emotions often lack rationality
You occasionally experience unexplained tears
Noise bothers you more than it used to, it seems louder than normal
You flare up at others more easily than you used to, you experience more anger
You feel depressed much of the time
You find you are more susceptible to pain
You prefer to be left alone